Self-Monitoring: Review of the Literature

1. Self-Monitoring: Review of the Literature Lora E. Burke, PhD, MPH, FAHA, FAAN Obesity Researchers Journal Club University of Pittsburgh October 21, 2008

2. Overview of Review • Self-monitoring – why • Historical review of studies, 1980s – present using paper diaries • Internet and electronic diary studies • What have we learned, where do we need to go

3. Self-Monitoring in Weight Loss • Is the systematic recording of one’s eating or physical activity behaviors • Purpose is to increase one’s awareness of eating behaviors • Should occur in real time, throughout day

4. Abbreviations • Behavioral weight loss program = BWLP • Physical activity = PA • Self-monitoring = SM • Intervention = Tx

5. “First” study of Self-Monitoring in Wt Loss (1) • Study involved 16 groups of 11 adults in a BWLP at a fee-for-service clinic for obesity; 15 weekly 1-hr meetings • 1/2 of groups given target behavior monitoring forms – 9 behaviors related to eating & PA, frequency count • # of times/day behavior was engaged in compared to total # of eating episodes = % compliance; graphed behavior; rec’d feedback Sperduto et al., 1986

6. “First” study of Self-Monitoring in Wt Loss (2) • Combining the 8 groups that used SM forms, mean wt loss = 15.9 ± 3.9 lbs vs. 9.7 ± 1.9 lbs for comparison group at end of Tx (15 wks), p <.005 • At 3-mos f/u difference was 6.4 lbs, p <.005 • Completion rate was higher among SM group, 74.4% vs. 56.8%, p <.05 • Implications: Need to begin to focus on eating behaviors, not outcome of wt loss Sperduto et al., 1986

7. Self-Monitoring and Weight Change: Cross-sectional Study • N = 56 obese adults previously Tx; agreed to participate in SM study • Given new booklet each week to record all foods, calories • Focus: examine relationship between SM and weight change • Result: Great diversity in percentage of Ss who SM and in type & frequency of variables monitored Baker & Kirschenbaum, 1993

8. Percentage of Days All Foods Were Monitored Baker & Kirschenbaum, 1993

9. Conclusions and Recommendations • 6 variables correlated significantly with wt change after 12 wks, e.g., SM any or all foods eaten, time eaten, quantity, gms. of fat • Ss in the highest level of SM lost sig more wt than those at the lower levels • Consistency/quality of SM in initial wks of Tx predicted wt loss over 6-mos period • Important to view SM not only as a process that mediates wt control but also an important outcome; focus more on behaviors that produce wt loss than on the wt loss • Need to develop means of sustaining SM Baker & Kirschenbaum, 1993

10. Further Support for Consistent SM • Study replicated Baker & Kirschenbaum’s 1993 study re: relationship between SM and wt control; N = 59 women in long-term BWLP; asked to participate in SM study for 8 wks • 26.3% SM all foods eaten on <50% of days • Most consistent SMs lost more wt, Ss lost more wt during time of consistent SM • Conclusion: Ss should SM at least 75% of the days; if SM <50% of days unlikely to succeed Boutelle and Kirschenbaum, 1998

11. Self-Monitoring and the Holidays • 2 studies (N = 32 & 57) examined effect of SM on weight gain among adults who had been in long-term Tx for weight loss • Findings: • Holidays were high risk period • Only the highly consistent SM quartile averaged any wt loss over 10-wk holiday period; least consistent SM gained wt • 2nd study showed that Ss SM more consistently during the pre-holiday period than during the holidays or post-holiday period; consistency was correlated with wt change (r = -.35, p = .007) Baker & Kirschenbaum, 1998;Boutelle et al., 1999

12. Comparison of 2 SM Approaches • 16-wk correspondence BWLP compared 2 methods of SM: traditional paper diary (n = 21, 45% retention) vs. traditional paper diary with transition to abbreviated diary with checklists at 8 wks (n = 21, 57% retention) • Results: Sig diff in # of diaries ret’d among completers (14.0 ± 2.0 detailed vs. 15.2 ± 1.4 transition group, p =.04) • No sig diff between groups in wt loss Helsel, Jakicic, & Otto, 2007

13. Number of Diaries by Groups Helsel, Jakicic, & Otto, 2007

14. Wt Loss in Two SM Groups TSM = transitioned to abbreviated SM, DSM = detailed SM Helsel, Jakicic, & Otto, 2007

15. Self-Monitoring Physical Activity • 6-mon BWLP, N = 40 obese, sedentary adults, 85% retention at 6 mos • Instructed to complete daily PA diary describing exercise type/duration; collected every 4-5 wks during 21-wk Tx • Examined association between SM exercise and wt loss and PA • Results: 8 drop outs + 5 Ss did not complete diaries; on average, 27 Ss completed 15.8 ± 6.2 wks of SM; greater SM assoc with wt loss (r = .44, p <.05), weekly PA (r = .52, p <.01) Carels et al., 2005

16. Differences Between Consistent & Inconsistent SM of Exercise • Insert figure 1 from Carels et al article Carels et al., 2005

17. Phase I of Wt Loss Maintenance Trial • 4-center, one group BWLP lasting 6 mos.; N = 1685, 44% minority; 92% retention at 6 mos. • Results: Ss completed 3.7 daily food records per wk.; men completed more diaries than women (p <.004) • After adjusting for race, gender & initial wt, greater wt loss with greater attendance, SM records & min of PA • Association between # FR kept per wk & wt loss greater for non-AA compared to AA regardless of gender Hollis, Gullion, Stevens et al., 2008

18. Effect of No. of FRs/Wk on Wt Change Hollis, Gullion, Stevens et al., 2008

19. Self-Monitoring in Internet Studies (1) • Study compared structured Internet BWLP to a weight loss education Web site; N = 91, 71% retention at 6 mos. • SM diaries submitted online, individualized feedback provided e-mail • Results: wt loss -4.1 ± 4.5 vs. -1.6 ± 3.3 kg • Ss submitted 13.65 ± 6.4 diaries during 24 wks, >50% of diaries submitted in 1st 3 mos. • Total # of diaries submitted related to wt loss, r = .50, p = .001 Tate, Wing & Winett, 2001

20. Self-Monitoring in Internet Studies (2) • Study compared Internet wt loss program alone to Internet wt loss + behavioral counseling via e-mail for 12 mos; N = 92, 84% retention at 12 mos. • Ss instructed to submit daily diaries for 1st month, thereafter option of daily or weekly diary, individualized feedback provided e-mail • Results: wt loss -2.0 ± 5.7 vs. -4.4 ± 6.2 kg • Logins to Web site sig greater in behavioral e-couns group (p <.05); logins correlated with wt loss, r = -0.47, p =.003 • Not clear if logins same as submitting diary Tate, Jackvony & Wing, 2003

21. Logins to Web Site Tate, Jackvony & Wing, 2003

22. Improving SM Adherence with Hand-Held Computers: A Pilot Study • Diet Modification arm of WHI, N = 33 • Personal digital assistant (PDA) system used for 1 month; Ss received immediate & weekly tailored feedback • Results: Ss significantly increased SM, improved attitudes toward SM, met dietary goals more often, reduced fat intake Glanz, Murphy, Moylan et al., 2005

23. Use of Technology in Self-Monitoring • Quasi-exp design, 6-mos BWLP compared paper diary (n = 115, 81% retention in a previous study) vs. PDA with Calorie King Diet software (n = 61, 93% retention) for SM and effect on wt loss • Results: No sig difference between groups in wt loss, SM, adherence; 32% of wt loss was explained by frequency of SM, p <.001 Yon, Johnson, Harvey-Berino et al., 2007

24. Adherence to Tx by PDA vs. Control Yon, Johnson, Harvey-Berino et al., 2007

25. PDA-Based SM in ENHANCE • 2-group RCT testing 6-mon behavioral Tx for self-mgmt of type 2 diabetes vs. attention control; N = 151, 85% retention at 6 mos. • Results: Adherence based on assumption of 3 meals + snack/day – entered 43% of expected meals; assuming 3 meals/day entered 58% of meals • End of study assessment revealed good acceptability of PDA: 88% understood usefulness of SM, 85% entering foods was easy, 70% could interpret graphs Sevick, Zickmund, Korytkowski et al., 2008

26. BalanceLog® on PDA

27. Nutrition Fact Sheet on PDA

28. Summary Feedback on PDA

29. Summary of PDA Studies • Software variable • Adherence defined and measured differently • SM occurred ~ 52-62% of days • Yon et al. (2006) reported that validity of energy intake did not improve with PDA; 41% of Ss categorized as low energy reporters • Software does not track date & time of SM

30. Use of Instrumented Paper Diary • Purpose of study: To examine and describe the actual patterns of self-monitoring among participants in a weight loss intervention study, using an instrumented paper diary* (IPD) *Stone, A, et al. 2002 • Conducted as an ancillary study to PREFER trial – 12-mon BWLP with 6-mon maintenance phase (n = 35, 13, 16 across 3 phases) Burke, Sereika, Choo et al., 2006

31. Method of Self-Monitoring Used • Instrumented paper diary (IPD) • Pages contained w/in a canvas binder • Photosensors are unobtrusively embedded in spine of binder • Circuit board is enclosed in back pocket • Photosensors detect when the binder is opened and closed; date-and-time stamped each action

32. Standard Paper Diary

33. Instrumented Paper Diary Photosensor detects opening & closing of binder Unobtrusive instrumentation records time/date -circuit board in right pocket Plastic ties lock rings closed invivodata, inc., Pittsburgh, PA

34. Card Reader to Upload IPD Data invivodata, inc., Pittsburgh, PA

35. Adherence Definitions • Reportedadherence – based on time Ss report recording • Conservative – record w/in 2 hrs. of eating • Liberal – record w/in 6 hrs. of eating • Actual adherence – based on measure of the IPD opening and closing • Faked adherence – difference between self-reported time and IPD recording • Hoarding – no recording of IPD open/closing yet there are diary pages that are completed

36. Adherent: IPD Report Time Day of Monitoring Period

37. Adherent: IPD Report and Self-Report of Eating Time Day of Monitoring Period

38. Adherent: IPD Report and Self-Report of Eating and Recording Time Day of Monitoring Period

39. Sample Diary Page - Adherence

40. Sample Diary Page - Adherence

41. Hoarding: IPD Report Time Day of Recording

42. Hoarding: IPD Report and Self-Report of Eating Time Day of Recording

43. Hoarding: IPD Report and Self-Report of Eating and Recording Time Day of Recording

44. Sample Diary Page - Hoarding

45. Summary of Diary and IPD Use

46. Summary of Diary and IPD Use

47. Summary of Diary and IPD Use

48. Summary of Diary and IPD Use

49. Correlations of Recording and Weight Change Baseline – 6 Months

50. Summary of Findings • Majority of time little concordancebetween self-reported and electronicallydocumented data • Data provide first evidence of actual patterns of self-monitoring among weight loss study subjects